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Fat as a Therapeutic Issue: Raising Awareness in Ourselves and Our Clients

Cheri K. Erdman, Ed.D., L.C.P.C.

I am in a unique position to talk about fat women in psychotherapy for several reasons: I’ve experienced what it’s like to live in a fat body for most of my life; I’ve been a (fat) client in therapy; and I’ve been professionally trained as a therapist. The combination of these experiences has made me acutely aware of cultural as well as psychotherapeutic prejudice against fat women.

Psychological theories about fatness, although not supported by research, proliferate in the profession. Freud was known to dislike fat people, theorizing that they were stuck in the infantile oral stage of development, repressing their anger and sexuality. Behaviourists have speculated that fat people get fat because their hunger response is stimulated by external rather than internal cues. Bodywork therapists have reported that fat people are armouring themselves, keeping memories and people away by building a wall of fat.

Add to this list the newer theories: All fat people have an eating disorder (from Overeaters Anonymous: “Thinness will not make you well, but wellness will make you thin.”); all fat women have been sexually abused; all fat women are symbolically telling the world they are angry and want to be seen as powerful and strong1; all fat people are depressed; all fat women are angry at their mothers2; and all fat women are fat because they don’t believe they deserve to be thinner3.

While it is true that some fat women have an eating disorder, some fat women have been sexually abused, some fat women are angry, some fat women are depressed, some fat women have bad relationships with their mothers, and some fat women feel undeserving, it is also true that non-fat women have these issues, too. Being thin does not guarantee that these problems won’t exist, nor does being fat guarantee that they will. Since most psychological theories about fatness derive from the unstated (and often unrecognized) assumption that being fat is pathological, these same theories automatically associate a multitude of problems with a large body.

I am not saying these theories and the theorists who construct them are intentionally trying to harm fat people. What I am saying is the theorists only have a theory, which by definition is not a proven fact. Theories are made by observations, which are always slanted according to the point of view of the observer and are affected by the observer’s biases.

If you agree there is a cultural bias against fat people but believe therapists are immune to its effects because of special training and sensitivities, I offer the following from a book chapter called “The Fat Lady” by the psychiatrist, Irvin Yalom: “I have always been repulsed by fat women. I find them disgusting: their absurd sideways waddle, their absence of body contour – breasts, laps, buttocks, shoulders, jaw lines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh . . .How dare they impose that body on the rest of us?”4. Dr. Yalom continues: “When I see a fat lady eat, I move down a couple of rungs on the ladder of human understanding. I want to tear the food away; to push her face into the ice cream. ‘Stop stuffing yourself! Haven’t you had enough, for Chrissakes?’ I’d like to wire her jaw shut”.

Although Yalom goes on to discuss a possible countertransferential basis for his fat phobic attitudes and finally comes to feel a tender connection with “The Fat Lady,” these quotations nevertheless make clear how automatic and deeply ingrained fat prejudice can be, and how bigotry can exist alongside all levels of education and professional credentials.

Contrast Dr. Yalom’s perspective with that of Drs. Laura Brown and Esther Rothblum: “We have just begun to integrate anti-fat-oppressive perspectives into the practice of psychotherapy. To do so, we must overcome within ourselves and our colleagues long and firmly held prejudices about the value of being thin. We must deal with our own fears of our female bodies, of being ample, taking space, carrying weight”5.

Yalom and Brown and Rothblum do not share the same point of view about working with fat women. Yalom’s perspective is firmly rooted in our culture, while Brown and Rothblum construe the matter differently. They challenge the belief that fat is equivalent to pathology, and their approach affirms that fat oppression, not fat, is the problem. While Yalom blames the individual, Brown and Rothblum criticize the culture.

If you are a therapist who is interested in broadening your personal, professional and ethical understanding of this issue, there are several things you need to do before you work with fat women.

First, reflect upon the following questions: Are you willing to see fat people differently, to shift your focus from fatness as a sign of pathology to fat as a cultural problem? Are you willing to look at your own fat phobia and work with it on a personal level? If you are a female therapist, confronting your fear of fat will more than likely change the way you feel about your own body. Will this change, and all of its repercussions, be welcomed into your life? If you are a male therapist, are you willing to confront your fat prejudice by becoming aware of how looksism, weightism and sexism play a role in your involvement with the women in your personal life?

If you are willing to change your personal and professional beliefs about fatness, the following steps are recommended as a way to prepare you to work with fat clients:

Become knowledgeable about weight, size and body image issues for women from an historical, cultural and size-diversity point of view. Exploring the historical context in which this issue thrives is imperative to understanding how this problem has developed. Look for research that supports a size-diversity paradigm rather than the fat-is-bad paradigm.

Engage in an on-going examination of your attitudes about fatness and reflect on how these affect your relationship with your body. Brown and Rothblum suggest that therapists acknowledge their own fat-oppressive attitudes without shame and then become engaged in consciousness-raising for more self-awareness. This will ensure that therapists are not fostering a prejudicial climate toward fat, fat people, or themselves.

Be aware of the ethics of working with clients who have food and body image issues while you are in the process of raising your own consciousness about these same issues. Brown and Rothblum believe that it would be unethical for therapists who are in the initial stages of developing their own awareness about food, eating, weight, and body image to work with clients who have these same issues. For example, a therapist who does not embrace a non-dieting, size-acceptance perspective in her own life is likely to send a double message to her fat clients: “It’s okay for you to stop dieting and accept your body, but it’s not all right for me.” Brown and Rothblum suggest that therapists instead spend their time creating a non-fat-oppressive attitude in their personal and professional support and consultation groups.

What are some concrete steps a conscious and ethical psychotherapist can take when treating a fat client who wants help with her weight issues?

Differentiate between weight status and disordered eating. Do not automatically assume that your fat client is also a binge-eater. If your client does express concern about her food and eating habits, help her understand that dieting only exacerbates the problem. If she wants to normalize her eating, assist her in ending her restrictive eating behaviour (dieting) as the first step in the process.

Help your client end playing the game, “I-blame-it-all-on-my-weight.” Assist her in understanding that while her weight may be related to her problems, it is not, in itself, the problem. The cultural bias against fatness, and the pain it causes our clients, makes it tempting for both therapist and client to make weight loss an important goal in therapy. The ethical therapist, however, understands, and will help her client understand, that fat and not-fat clients struggle with many of the same problems. Losing weight is the standard, culturally endorsed, easy answer. Focusing on problems other than weight takes courage and creativity from both the therapist and client and consequently will bring more lasting change into a client’s life. If a client is insistent that she must lose weight, the therapist can be an advocate for a healthy lifestyle that includes regular, moderate, enjoyable exercise, nutritious eating, and a balanced lifestyle. The goal is to focus on optimal mental and physical health regardless of weight.

Be prepared to discuss any feelings of pain, desperation and anger that may be part of your client’s experience of being fat. Help your client question the social pressure to be thin. Educate her to understand that the “weight problem” she experiences as her personal failing is the culture’s weight problem. Empower her to transform her self-blame and anger into creative action directed at changing the culture, not her weight.

Develop alternative treatment approaches. Encourage your client to increase her self-acceptance. Insight into this process can be found by examining the various themes found in Nothing to Lose6 that have come from interviews with non-dieting, size-accepting fat women. The spiral of acceptance described in this book can be used as a model for understanding the process.

Assist your fat clients in finding additional support for a non-dieting, size acceptance lifestyle. Your client will probably be tempted to go back to the old solution of dieting if she is not surrounded with people (including you) who accept her regardless of weight. Support can be found in many ways, including reading books and magazines about size acceptance and by joining local and national size- acceptance groups such as the National Association to Advance Fat Acceptance (NAAFA).

Empower your fat clients with both the knowledge and the right to confront you if fat-phobic attitudes surface in therapy. This kind of empowerment will be beneficial to both parties – you will learn how the subtleties of fat-phobia still affect your work and your client will learn to stand up to authority while standing up for herself.

Not all psychotherapists are suited to work with fat clients, and not all fat clients are ready for the kinds of interventions I am recommending. However, having a non-dieting lifestyle and a size-accepting attitude about yourself and your clients will provide an environment where they could assimilate, or at least be open to, similar attitudes and behaviour. As in all therapeutic situations, the ethical responsibility of the psychotherapist is to be fully prepared to deal with his or her own issues while moving their clients along with their chosen goals.

Mixed messages?

Ensuring that we are consistent in our messages of size acceptance is important. This includes making our environment as “size-friendly” as possible. There are many small and easy things that we can do to make individuals of all sizes feel comfortable:

Sturdy, armless chairs, or a loveseat that is firm enough for a large person to readily get up and out of, can relieve the anxiety and discomfort a client may feel.

Attention to the images that decorate our walls: Is there a diversity of body size illustrated? Or are the images of a single ideal body replicated? NEDIC, among other sources, has lovely posters that celebrate the diversity of our natural sizes.

Does the literature and reading material in the waiting area reinforce the idea that a thin body is the only acceptable body? Magazines on the market place which encourage readers to be active, vibrant participants in all areas of their lives, regardless of size, in addition to magazines of general interest, create an ambiance of acceptance and support in waiting areas.

These are but a few of the ways in which we can reinforce our stated claims to accepting and celebrating the diversity of our clientele.

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